the sights and rights of the blind

7/23/2019 The Sights and Rights of the Blind

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UNIVERSITY OF ILORIN

THE ONE HUNDRED AND ONE (101st)

INAUGURAL LECTURE

THE SIGHTS AND RIGHTS OF

THE BLIND

By

Professor Abdulraheem Olarongbe MahmoudMB;BS, FMCOph, FWACS, FICS

Cert Vitreo-Retina Surg, Cert Health Program Leadership

Department of Ophthalmology, Faculty of ClinicalSciences, College Of Health Sciences

Thursday 15th

March 2012


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This 101stInaugural Lecture was delivered

under the Chairmanship of:

The Vice Chancellor

Professor Is-haq Olanrewaju Oloyede

B.A., M.A., Ph.D., P.G.D.E. (Ilorin)

March 2012

Published by

The Library and Publications CommitteeUniversity of Ilorin; Ilorin, Nigeria


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Professor Abdulraheem Olarongbe Mahmoud

Professor of Ophthalmology, College of Health Sciences,University of Ilorin, Ilorin, Nigeria


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CourtesiesThe Vice-Chancellor

The Deputy Vice-ChancellorsThe Registrar and other Principal OfficersProvost, College of Health SciencesDeans of Faculties particularly Clinical SciencesChief Medical Director, UITHHeads of Departments particularly OphthalmologyMembers and non members of Academic staffMy Lords, Spiritual and Temporal

Ladies and Gentlemen of the PressInvited GuestsGreat Unilorin StudentsDistinguished Ladies and Gentlemen

IntroductionI begin this lecture on a note of expression of my

gratitude to the University Administration for extending theestablished precedence of giving an accelerated slot topresent an inaugural lecture to a department that has neverhad such an opportunity in the past. The most recentexample of the utilisation of such privilege is, of course, theDepartment of Surgery in which one of her newlypromoted professors presented his inaugural lecture in Julylast year, just a few months after his elevation. ThisUniversity privilege, no doubt, will continue to serve as theconcluding step in the University initiation rites, to enablesuch departments take up their rightful places among thealready initiated ones, and also serve as motivation for theun-initiated ones to become so in no distant future.


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By implication, I am also serving you a notice that youshould please bear with me as I am just a baby professor

presenting the first ever inaugural address of a yet-to-beinitiated department. Even then whatever credits that mayemanate from my inaugural lecture today are to be sharedwith my teachers and mentors, and all the mistakes andshortcomings should be entirely mine.

The novelty of this lecture also makes it imperative forme to make some introductory remarks on some basic andother pertinent issues related to Ophthalmology and eye

health. The necessity for this is even more so in a gatheringsuch as this which comprises of the members of the Townand Gown of diverse backgrounds and disciplines. Maybeyou will all derive some comfort in knowing that eventhose of us in the inner sanctum of the ophthalmicprofession equally get our tongues occasionally twisted inpronouncing the word ophthalmology and also misspell it!

Brief Historical Notes and DefinitionsOphthalmology is that branch of medicine that deals

with the art and science of eye health. Sight, as we allknow, is the most prized possession of all the senses. Thespiritual dimension to the origin of ophthalmology runsthus: In the beginning as we all remember, God made lightand to primitive man, worship of the sun-god, the giver ofthe heat and light that sustained his life, was almostuniversal. So godliness was equated with light and evil withdarkness and thus they remained. I am certainly notqualified enough to dispute this with the renowned Britishophthalmologist Mr Trevor-Roper who made the assertion1.Nearer home, an icon of Nigerian ophthalmology, DrAkinsete2credited Arabs and Muslim oculists with a lot of


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advancements in the practice of ancient ophthalmologysome of which included licensing procedures for oculists,

development of health institutions, scientific discoveriesand stating a safe criterion (active pupils) before couchingcould be undertaken for cataract. The fact that northernNigeria had been exposed to Arab civilisation through thespread of Islam for at least a millennium, would explainwhy couching for cataract- which used to be the universallyaffordable and accessible surgery to restore sight for thecataract blind - is still being practised there till today. The

first-ever video documentation of this couching procedureworldwide was recorded by our research team3in 1998, andit won the Association of Cataract and Refractive Surgeons(ACRS) prize in San Diego in 1999 (Figure 1).

Figure 1: Prof Reinhardt-Koch of Germany flanked byProf Mahmoud (L) and Mallam Liman (R), posing with theASCR prize won for the research on traditional lenscouching practices in Nigeria.


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Orthodox eye care delivery began relatively early inNigeria in 1942, when the Sudan Interior Mission (SIM)

established the first eye hospital in Kano4

. Eye care wasand still is essentially curative ophthalmology based ondoctors, nurses and technology5. Though by now, each stateof the Nigerian Federation has at least an eye unit in hertertiary health facility, the fact that these units are situatedin big cities and towns ensures that eye health services arerelatively inaccessible to the rural populace. In the past andparticularly in the north, the mobile field units that were

established to extend health care to rural areas throughlinkages with native dispensaries were highly effective6.Rodger noted during a blindness survey in northern Nigeriathat the recognition by the peasants of the different diseaseswhich might lead to blindness had been greatly helped inthose years by the increasing widespread contacts with themobile field units and village dispensaries7.

However in the present day Nigeria, no such

harmonious linkage exists in between the different tiers ofhealth care. This, alongside many other challenges havecrippled health care delivery in Nigeria to such an extentthat any Nigerian with the means would rather go for healthcare abroad particularly to India, for treatment of mostailments including ocular ones.

The major challenges centre on poor resourcesallocation. It would appear that successive Nigeriangovernments have been clinging to the old notion thatviewed social services spending such as health andeducation as a dissipation of national resources5. Theywould therefore favour spending on industry, dams androads which tend to have more measurable and immediateimpact on national development5. Within the health sector,


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priority setting for allocation of resources betweenepidemic diseases that result in mortality such as malaria

and Acquired Immune-deficiency Syndrome (AIDS), andthose that only result in morbidity and disability such asblindness tend not to favour eye health.

Some realities in life are best defined by their oppositesso it is with sight i.e. blindness. At this juncture, pleasepermit me to make some definitions of some terms andconcepts in ophthalmology in order to enable us all to havea common basis in following this lecture.

Definition of blindnessAn individual is said to be blind when he or she cannot

see the out-stretched fingers of an adult hand placed threepaces afar with both eyes open. In ophthalmic parlance, wedenote such visual acuity as being worse than 3/60. Ifvision is better than 3/60, but not exceeding 6/18, theperson is said to have low vision. Both blindness and lowvision constitute gradations of visual impairment. Of

course, there are more technically exacting definitions ofblindness, some using additional ophthalmic parametersand even some on legal and social criteria.

- OphthalmologistA medically qualified (physician) who further

specialises in medical, surgical, and optical cares of theeyes.

- Optometrist

A non physician science university graduate, who istrained in the measurement of visual function and so also inbasic eye care.


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- OpticianA technician suitably trained in the fashioning and

repair of ocular devices and appliances such as eye glassesand contact lenses. However in some countries,optometrists are referred to as ophthalmic opticians whileopticians are referred to as dispensing opticians.

- Orthoptist

A science graduate suitably trained in the neuro-muscular coordination of the movements of the eyes. He or

she assists the ophthalmologist with the treatment ofchildren with squints or strabismus.

- Ophthalmic nurses

These are state registered nurses who specialise furtherin eye care nursing.

- Unilorin

University of Ilorin, Ilorin, Nigeria.

Rationale and Premises for the Topic of my LectureIt is only after dispensing with the introductory remarks

above that I can now safely dispel the seeminglycontradiction inherent in my lecture titled The Sights andRights of the Blind.The moral and legal obligations that are inherent in therights of a blind person include the following:

Most of the blind individuals ought not to havegone blind in the first instance if the collectivesociety had not failed in their social responsibility(primary prevention of blindness).


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For some individuals that have gone blind, theirsight could be restored using existing knowledge

and curative technology (secondary prevention ofblindness).

And when all else have failed and the individualremains incurably blind, it is his or her right to livea productive life in dignity (tertiary prevention).

The avoidably blind persons include those blind fromcauses that stem from the failure of the society to preventfrom occurring ab initio and those who could have their

sights restored constitute about three quarter of the 37million blind persons worldwide8. A million of these areNigerians, who in the main are poor illiterates with femalepreponderance residing in the poorer parts of Nigeriaparticularly in the North-East geo-political zone9. In KwaraState, our research survey of blindness and ocular motility10revealed a prevalence of blindness of 3.4% with the threemajor causes: cataract (34.3%), glaucoma (40%) andonchocerciasis (11%) being all avoidable. In effect, thesheer magnitude of blindness as a public health burden isawesome internationally, nationally and within ourimmediate catchment area in Kwara State. Worse still, isthe fact that a sizeable chunk of the 75% of the causes ofthis blindness could either have been prevented outright orcured to restore sight i.e. avoidable, if appropriate eye

health resources were made available and or deployed inthe right mix and as at when needed.An international collaborative effort: VISION2020 -

The Global Right to Sight initiative, was launched in 1978to combat avoidable blindness. The strategies to achievethe stated goal of halving the prevalence of avoidable


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blindness by the year 2020 were formulated as follows:disease control, manpower and infrastructures.

The three rationales earlier listed for my topic: primary,secondary, and tertiary prevention, in addition to manpowerdevelopment, appropriate technology, health management,advocacy and resource mobilisation are the sevenperspectives in which I wish to showcase mycontributions to extending the frontiers of knowledge inophthalmology. This task, though helpfully camouflaged asan inaugural lecture, is a daunting one for a debutant

professor.The academic scientist in me compels me to disclose

first the sources of my experiences that have shaped all theresearch undertakings that I am sharing in this lecture, all inthe spirit of full disclosures. They include my experiencesas an ophthalmic surgeon that has been opportune topractise in three continents of the world; a researcher withvast international collaborative research undertakings; an

eye health administrator which was honed by mystewardship as the National Coordinator for the NigerianNational Programme for the Prevention of Blindness((1994-1999); and last but not the least, a medical lecturerwho has supervised over a dozen Fellowship desertions andwho regularly examines at the highest levels (part 2) ofboth the Nigerian Postgraduate Medical College and theWest African College of Surgeon.

Primary Prevention of Blindness and Health Care

EducationThe ultimate goal for my works appraised in this

section is to influence the populations way of life so thateye health is promoted or maintained, and eye diseases


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prevented. Some ocular ailments, environmental hazards toeye health, and eye-related health problems can be

prevented from occurring. Typical examples includeCredes prophylaxis for ophthalmia neonatorum, andwearing of protective goggles in some occupational settingssuch as the one showed in Figure 2 which is from a lasertreatment room.

Figure 2: Goggle worn in the laser treatment room forprotection of eyes

Everyone else in the laser room with the exception

of the laser surgeon and his or her patient has to wear thegoggle shown to protect the eyes from un-intended laserradiation. An inter-sectoral collaboration with our othermedical colleagues, allied health staff, agriculturist,educationists, experts in water resources and environmentalsanitation is vital to eye health in general and eye health


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promotion (primary prevention) in particular to succeed.Self sufficiency in food production would ensure food

security and thereby eliminate malnutrition and its ocularcomplication. An educated citizenry will have a betterunderstanding of the various measures necessary to keepeyes healthy.

Involvement of teachers with the screening of theirpupils eyes and the recognition of the potentially injuriouscorporal punishments in Ilorin were areas that wereexplored in our multi disciplinary research in a study

carried out in 2005. In the first segment of the study, theexpected roles of elementary school teachers were probed.These roles include:- Visual screening of pupils to detect those with bad

eye sight- Detecting changes in the eyes as soon as they occur- Giving simple first aid treatment such as removal of

superficial foreign bodies from the eyes

- Teach pupils on safety, prevention of injuries, facewashing, good nutrition, and adequate ambientlighting.

- Keeping parents informed of any visual problemdetected and impressing it on them to comply withany referral made for their wards to the eyespecialists.Our encouraging conclusion from the study runs

thus: majority of the teachers appeared to have anadequate knowledge of the correct attitude to, and correctpractices of, the factors that have positive bearings on theirpupils eye health11. In the second segment of the study12,elementary school teachers self-reported their observationsand knowledge of corporal punishment practices in their


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schools. Over 80% of the 172 teachers confirmed the use ofa cane on pupils with a fifth indicating they were applied to

the head and 16.3% to the face of the pupils. Therecommendation from our findings was that if at allteachers must administer corporal punishments, they wereenjoined to use non-abusive forms and that NEVER shoulda cane, a belt, or a bunched broom stick be used to beat achild on the head or face, as the eyes of the struggling childcould easily be injured in such circumstances.

In the third segment of the study, the knowledge

and attitude of the other group of care givers i.e. parentsand guardians towards their pupils eye health wereprobed13. We inferred that a significant proportion of theseguardians would not recognise eye ailments in their wardsand when a few did, they would treat with self prescribedand harmful traditional eye medications.

In a study on traumatic hyphaema (traumaticinternal bleeding into the front part of the eyes), we found

out that close to three quarters of the 23 patients studied didnot report to a hospital within 24 hours and this led toserious sight-threatening complications in 20 of the patientsafterwards14. From the analysis of the tabulation of thehuman activities that led to the injury (Table 1) it will beobvious that they were all eminently preventable withappropriate eye health education messages.


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Table 1: Patients activities that led to traumatic

hyphaema in Ilorin

ActivitiesChildren being disciplinedChildren at playDomestic accidentsSports injuryAssaultOccupational accident

Frequency566222

Total 23

Our findings from a study among 100 individualswho had just then watched the solar eclipse that occurred inNigeria on 29thMarch 2006 included the fact that forty ofthem viewed the eclipse through the naked eye, despiteadmitting to having been adequately counselled on thehazards in the mass media by the likes of my humble self15.We however noted that the filter goggles that were

recommended to the populace for viewing solar eclipseswhich would have blocked harmful rays that could burn offthe macular in the retina at the back of the eye (solarretinopathy), were largely unavailable and relativelyexpensive. Hence one of the recommendations we madefrom this study, was for our governments to arrange massimportation of such goggles for mass distribution duringfuture solar eclipses since the dates of future occurrencesare usually accurately predicted well in advance.

A survey of the use of ocular self medication revealedthat 79% of the 200 respondents were guilty

16. The array

of self-prescribed medications included over the countereye drops (84%), herbal preparations (11%), and powderycontents of tetracycline antibiotic capsule (3%). The


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remaining 2% included various substances that had beenspiritually conditioned or blessed. Our recommendation

was to target and mitigate the reasons that these individualscited as being responsible for their resort to using selfmedication as tabulated (Table 2).

Table 2: Reasons cited for resort to ocular self medicationREASONS

Financial constraintI know what to doAilment was minor

Eye care not readily availableLack of escortIgnorance of adverse effectsTOTAL

FREQUENCY231865

28320

157

PERCENTAGE14.611.541.4

17.81.912.7100

The welders goggle was the subject of our study17in 2006. The major finding was that despite the fact that allthe eighty welders interviewed were aware of the ocular

protective property of the welders goggle, only 17.5% ofthem wore their goggles always. Our recommendationwas for an appropriate health education message which willintimate them properly with the necessity of wearing thegoggles at every single welding episode i.e. at all times.

An interesting study with equal measure for healtheducation potentials for both the eye health workers andtheir patients was conducted shortly after the completion of

the 2006 annual Muslim Ramadan fast18

. The study aimedto ascertain the modifications in ophthalmological caredesired by fasting Nigerian Muslim patients who happen tobe the predominant inhabitants in and around Ilorin. Nearlyall respondents wanted their routine appointments(95.80%), routine in-patient care (92.4%), and elective


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surgery (93.2%) be re-scheduled to outside the month ofthe fast. Sixty percent would object to their having an

injection during the day-light hours of the mandatoryabstinence from eating and drinking. Majority preferredthat the dosage requirement of their topical eye medication(82.1%) and oral drugs (93.9%) be adjusted to no morethan twice a day so as to avoid taking those medicationsduring the hours of fast (5am-7pm). The implications fromthis study include the need for health education messages tobe drawn up with the imprimatur of knowledgeable Islamic

leaders, which would inform the Muslim patients of theirlegitimate waivers on fasting as magnanimouslyextended by Islam to ill patients and those on criticalregular medication and food intakes such as diabetics andulcer patients19. And that non-oral medication such as eyedrops, inhalers, ointments and balms do not necessarilyvitiate fasting and hence eye drops can be applied withoutfear by fasting Muslims. On the part of the eye health

workers, they should be encouraged to realise that religiousconviction has strong emotional basis, hence they shouldnot adopt a take it or leave it approach when theirpatients religious stance appears to conflict withconventional medical wisdom. Rather, routine non-critical appointments, procedures and (eye) operationsshould be arranged to outside the Ramadan fast for theirMuslim patients; and equally potent once or twice a day

eye drops and oral medications could be substitutedwhenever possible. Fewer daily dosage regimes generallyimprove compliance with therapy by patients of whateverreligious beliefs anyway!

The study on couching earlier alluded to revealedthat couching as practised by traditional eye doctors who


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specialised in this surgery to be a very crude procedurethat was fraught with dangerous sight-threatening

complications, including infections from their un-hygienicinstruments and environments3. We however recommendedthat educating the populace about the danger of couchingon its own was unlikely to be heeded if the present situationof orthodox cataract surgery remains largely inaccessibleand un-affordable and somewhat also fraught with equallysight threatening complications as well. The members ofthe public appear more un-forgiving of the occasional

mishaps that follow eye operations in our orthodoxhospitals than the plentiful ones from traditional couchers,probably because being that the latter are itinerant lots, theywould not be any where nearby for their patients to pointaccusing finger to, after surgery.

Wearing of eye glasses (spectacles) has never beenovertly popular among the wider African populace for avariety of reasons. In a study among 100 adults, who had

earlier obtained prescription glasses, 71% only wore theirglasses occasionally i.e. less than 50% of the times theywere supposed to use them for the intended purpose e.g.reading and distance vision20. None wore his or her pair ofglasses always i.e. at all times it was supposed to be used.The reasons cited for not wearing their glasses alwaysincluded lack of felt need which had cultural underpinnings(58%), spectacle intolerance (28%), and ignorance (14%).

Nigerians have been known to fear the stigma of eyeailments, particularly those requiring prescription glasses,as they are deemed to indicate weak and/or diseased eyeswith the ominous implication for the development ofblindness in the future21.


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The last but not the least of my seminal worksbothering on eye health promotion is perhaps the most

dramatic. It centred on the analysis of all the eye healthenquiries phoned-in live to me by 27 callers while I wasanchoring a two-hour long phone-in nationwide audienceparticipation radio programme

21. The event held in the

studio of the Federal Radio Corporation of Nigeria inAbuja on Saturday 3rd April, 1997 at the tail end of ablindness-awareness week organised by the NationalProgramme for prevention of Blindness of which I was

then the National Coordinator. Table 3 shows a listing ofthe enquiries made as categorised by the aspects of theprevention of blindness activities they belonged to. One ofthe implications drawn from the study is the need foreducators to alter the format of health education messagesfrom only blinding eye diseases entities such as cataractand glaucoma, to functional descriptive formats such asitchy eyes, red eyes, blurred eye sight, etc, in order to

connect better with the populace.


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Table 3: Grouping of enquiries on prevention of

blindness made by 27 callers at a radio phone-in

programGROUP SUMMARY OF ENQUIRY GROUP TOTALTreatment ofcure for

blindness

- Any vaccine to preventblindness?

- Is blindness curable?- Are over-the-counter eye

drugs safe?- Could traditional healers

be consulted for eyeproblems?

-

Are home remedies safe?- Can diseased eyes be

transplanted with seeingones?

- How could the blind berehabilitated?

7

Implementation strategies

- What are the activities ofthe national agency for

prevention of blindness?

-

What takes place in eye-camps

- Could eye care items bemade cheaper?

3

Specific EyeDiseases

- What causes blindness?- Will red eyes lead to

blindness?- Will persistently itchy

eyes go blind?

-

Will crawly feelingaround the eyeseventually lead to

blindness?- What is cataract eye

disease?

5

Radiationsand the Eye

- Are radiations fromcomputer screen harmful

4


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to the eye?- Are radiations from

television screen harmful

to the eye?- What are the dangers of

x-ray exposure to the eye?- What are the dangers of

ultrasound examination ofthe eye?

Optimallightingconditions

What are the optimalrecommended lightingconditions at

-

Home?- Work?- Are extra vehicle headlamps

permitted for use whiledriving at night?

3

Wearing ofglasses

- Will wearing of glassesspoil children eyes?

- Is wearing of glasses asign of diseased eye?

- Does wearing of glassesindicate blindness later inlife?

- Are sun glasses safe towear?

- Why do some peoplewear sun glasses even atnight?

5

Secondary Prevention of Blindness and Disease Control

The ultimate goal in eye disease control is to provide anadequate medical, surgical and optical treatment toindividuals affected by eye diseases so that diseases arearrested at an early stage and loss of vision is prevented.Typical examples include glaucoma and diabeticretinopathy screening, and lid surgery for trachoma and


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leprosy, to prevent blindness. But firstly we have to heedthe admonition of General Sun Tzu in his timeless treatise:

The Art of War. He advised thus: know thyself; know thyenemy. You will fight a thousand battles without defeat.The enemies in our own context are the blinding diseases;hence we need to know them properly by determiningtheir epidemiological characteristics and magnitude of theproblem that they cause so as to enable us wage successfulwars (control measures) on them.

Surveys and other Epidemiological StudiesOur survey of blindness and ocular morbidities in

Kwara State in 2003 proved exceedingly useful in gaugingthe magnitude of blindness as a public health problem inthe state10. The array of ocular morbidities detected asclassified by the WHO categories of visual impairment isas contained in Table 4.


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Table 4: List of Eye Diseases by WHO Categories of VisualImpairment

DIAGNOSIS UNIMPAIRED LOW

VISION

BLIND TOTAL

Cataract 38 (58.5%) 49 (55.1%) 12(34.3%)

99 (52.4%)

Glaucoma 11 (16.9%) 16 (18%) 14 (40%) 41 (21.7%)

Corneal scar 3 (4.6%) 3 (3.4%) 1 (2.9%) 7 (3.7%)

Onchocerciasis

- 2 (2.2%) 4(11.4%)

6 (3.2%)

Retinopathy 2 (3.1%) 4 (4.5%) - 6 (3.2%)

Refractiveerror

- 5 (2.2%) - 5 (2.6%)

Squint 5 (7.7%) - - 5 (2.6%)Conjunctivitis 4 (6.1%) 1 (1.1) 5 (2.6%)

Aphakia - 2 (2.2%) 1 (2.9%) 3 (1.6%)

Trachoma - 1 (1.1%) - 1 (0.5%)

Pterygium 1 (1.5%) 1 (1.1%) - 2 (1.1%)

Optic atrophy - 2 (2.2%) - 2 (1.1%)

Phthisis bulbi - 1 (1.1%) 2 (5.7%) 3 (1.6%)

Bandkeratopathy

- 1 (1.1%) - 1 (0.5%)

Maculopathy - 1 (1.1%) - 1 (0.5%)

Conjunctivaltumour

1 (1.5%) - - 1 (0.5%)

Childhoodblindness

- - 1 (2.9%) 1 (0.5%)

Total 65 (100%)* 89 (100%)* 35(100%)*

189(100%)*

The restoration of sight to the cataract blind whooften constitute about half of all the blindness in various

parts of the world, is one of the most cost effective heathintervention programme as complete sight can be restoredto cataract blind patients through a relatively simple eyeoperation. Our main recommendation from this survey isfor the institution of a cataract surgical outreach eye careservice which would ferry the Ilorin-based


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ophthalmologists on a regular basis to the Kwarahinterlands to operate on eye patients in the communitiesdistrict hospitals. Unilorin, through her associate teachinghospital, has been providing her ophthalmologists assurgeons to operate on the cataract blind ever since, underthe auspices of Kwara State government eye care plan. Thisis a worthy example of the excellent Town and Gownrelationship for which Unilorin is renowned for, and also aclassic case of Muhammad (or rather, Mahmoud) going tothe mountain, as the rural inhabitants rarely have the means

and inclinations to travel to the big towns and cities such asIlorin to have their eye operations. Indeed, a blueprint for anationwide cataract surgical outreach for Nigeria had beendrawn up as far back as 1999 by the National Committeefor prevention of Blindness when I was serving as theNational Secretary

22. Figure 3 is a picture of an eye with

cataract while Figure 4 shows the operating room setup fora cataract operation.

Figure 3: Cataract in the left eye of an elderly woman


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Figure 4: Cataract operation: operating theatre room scene

Another survey by our research team in Osun Statein 2005 studied blindness and low vision in the over 50year-olds in Egbedore Local Government area (LGA)23.

The prevalence blindness was 6.3% (75/1183) and 223 hadlow vision (18.9%). Overall the prevalence of blindness

and of low vision increased with age.Our survey among children in10 randomly selected

primary schools within Ilorin metropolis conducted in 2003revealed that 19.9% (270/1,393) had ocular morbidities24.These included vernal conjunctivitis (6.7%) refractiveerrors (6.9%), congenital/developmental diseases (2.8%),


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juvenile glaucoma suspects (1.4%), and others (2.1%). Werecommended for an effective school health programme(with eye health component) in primary schools toappropriately screen and refer as appropriate children withocular morbidities. From the same survey, the subset ofschool children diagnosed as glaucoma suspects werefurther analysed in a separate study25. Having noted that thecombination of tonometry and fundoscopic criteria used inthe study increased the sensitivity and specificity ofdiagnoses to 61% and 84% respectively, we strongly

advised the guardians of these children to make thechildren available for regular glaucoma screening at theteaching hospital twice a year, in order to detect theestablished glaucoma disease at a very early stage,whenever it developed. Visual loss and blindness inglaucoma are irreversible, hence, the linchpin of controllingblindness from glaucoma is to detect the disease early andinstitute appropriate treatment. The 11 children (8 boys and

3 girls) with ocular trauma from the same survey included 2whose eyes were already phithisical, one with couchedlens, and one with retinal detachment and all the three werealready blind in the affected eye26. Two more of the eyeinjured children had bruises of the eyelids and one each hadhyphaema, lid ecchymosis, eyelid laceration, andconjunctiva haemorrhage. Four of the children got injuredwhile playing, 3 during corporal punishment, 2 during

fights, 1 domestic accident, and 1 after undergoingcouching for cataract. The need for fashioning appropriateeye health education messages to prevent these injurieshave been discussed earlier

The risk factors for children with squint (strabismus orcrossed eyes) were the subject of a study among 7,288


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children attending schools in Ilorin South LocalGovernment Area (LGA) who had the eye problem27.Among the 32 of them that had squint, we found a strongassociation between heredity, significant hypermetropia(long sight) and strabismus and recommended that ourcolleagues managing this condition should include theevaluation of these identified risk factors.

The pattern of orbito-ocular neoplasm in Ilorin28 from1985 to 2005 was determined in another study to be asfollows: non-neoplastic (36/92), benign (18/92), malignant

(37/92), and pre-malignant (1/92). The specificcharacteristics of these tumours are as shown in Table 5.

TABLE 5: Distribution of tumours by neoplasia status, mean age

and sex ratio

TUMOURS NO OFCASES

% M:FRATIO

MEANAGE

Non-neoplastic (n=36)

Pterygium 14 15.2 1:1.6 44.4

Granulomapyogenicum

7 7.6 1:1.3 25.4

Epidermal inclusioncyst

4 4.3 1:1 29.3

Others 11 12 1.6:1 35.6

Benign (n=18)

Conjunctivalpapilloma

11 12 1:1.2 37.1

Capillary

haemangioma

4 4.3 3:1 17.6

Others 3 3.3 2:1 22.3

Pre-malignant (n=1)

Carcinoma in situ 1 1.1 0:1 60

Malignant (n=37)

Retinoblastoma 21 22.8 2:1 3.4


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Squamous cellcarcinoma

8 8.7 1:1 42.1

Others 8 8.7 1.7:1 35.4

Total 92 100 1.2:1 28.2

One of the tumours malignant fibroushistiocytoma in the orbit of a 3 year-old Nigerian girl could bear further mention. That type of tumour occurringin the orbit of a child is so rare that the diagnosis was onlymade by the histopathologist after the child had hadsurgical exenteration of the cancerous growth. This once in

a blue moon experience and the other diagnostic challengesthat we faced in managing this child were appropriatelyshared with our colleagues

29. We learnt from another study

that a lot of our people were not aware that cancer couldaffect the eyes and the few that did had so muchmisconceptions as to the possible aetiogenesis and thecorrect actions to take in seeking eye health care30.

Onchocerciasis (river blindness)A quarter of a million people world-wide are blind from

this disease caused by an infection with onchocercalvolvulus, which is transmitted from person to person byblack flies (Simulium species). Since black flies breed nearfast flowing rivers (hence the name), river blindness ismore prevalent in the fertile agricultural lands in the West

African sub region including Nigeria. The first study in1990 in Nigeria, in which I participated, established thesafety and efficacy of ivermectin (mectizan) tablets in theprevention of blindness from onchocerciasis through areduction of the incidence of optic nerve disease in heavilyinfected individuals31. This finding, among others has


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greatly streamlined drug control of river blindness to justonce a year dosing of the residents of infected communitieswho have no contraindications to the drug (ivermectin).

The second study on onchocerciasis was commissionedby the African Programme on onchocerciasis control(APOC) and it was conducted in oncho-mesoendenic partsof Taraba, Kogi and Cross River State32. Our findings fromthis study in these three different ecological zones includethe fact that onchocerciasis was responsible for about athird (30.3%) of the blindness prevalence of 2.4% across

these study sites. Anterior segment onchocercal lesions,punctuate and sclerosing keratitis were the predominantfeature of the onchocerciasis infection in the Savannahzone, while posterior segment lesions were more commonin the forest zone.

Laser Treatment of Retino-Vascular DiseasesMy interest in the use of ophthalmic laser devices began

as far back as the late 1980s at the beginning of myresidency training at the Guinness Eye Unit in Kaduna,Nigeria. There, I somehow occasionally succeeded inwaking up a disused xenon arc photo coagulator to treatmicro aneurysms at the centre of circinate exudates andabnormal new vessels in diabetic retinopathy. It did nottake long for me to discover why my predecessors hadwisely archived the xenon-arc device, as though the

patients eye were unharmed, I got electric shocks to myface and cheek each time I used the xenon photocoagulator. Much later, my interest in laser got resuscitatedin 1992, when after I have been appointed as an honoraryregistrar at the Leicester Royal Infirmary, United Kingdom(Figure 5), I discovered that the laser equipment there did


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not come with an electrocution package for its lasersurgeon operators.

Figure 5: The Leicester Royal Infirmary, Leicester, England

I was trained further in laser treatment during myvitreo-retinal sub-speciality fellowship at the El MaghrabyEye Hospital Jeddah, Saudi Arabia (Figure 6) from 1995 -1996. It was in the latter place that I treated two of the threepatients in whom laser treatment failed to regressneovascularisation in proliferative diabetic retinopathy33.


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Figure 6: El Maghraby Eye Hospital, Jeddah, Saudi Arabia

A diode laser was procured for my retinal clinic atthe National Eye Centre, Kaduna in 1997. The 32 eyes of26 patients who had laser treatment between 1997 and 1999were the subjects of the pioneering ophthalmic laser studyin Nigeria

34. The conditions treated with laser included

proliferative sickle-cell retinopathy (8 eyes of 6 patients),diabetic retinopathy (12 eyes of 9 patients), central retinalvein occlusion (2 eyes of 2 patients), flat retinal breaks (3eyes of 3 patients), and refractory glaucoma (7 eyes of 6

patients).though all the patients completed thepredetermined course of laser treatment successfully,complaints of pain were universal and there were poorresponses in those with advanced forms of proliferativechanges in whom laser was only used as a palliativemeasure.


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An audit of ophthalmic laser procedures performedin Ilorin from 28th August to 4th September 2006 duringthe visit of the Orbis Flying Eye Hospital programme wasundertaken35. The audit report lamented that patients withretino-vascular disease did not benefit from the lasertreatment given as generally their advanced proliferativechanges needed vitreo-retinal surgery in addition to lasertreatment. The recommendation for the procurement of themuch needed vitreo-retinal equipment and instruments andconsumables has been taken up by the Unilorin

administration recently. In the mean time, the University ofIlorin Teaching Hospital had procured the latest model ofdiode laser (Figure 7) which has been put to use and doesnot give electrical shocks to surgeons! With this hazard ofelectrocution that welcome me at the beginning of my lasertreatment career now permanently and mercifully out of theway, the chance of my being around for about two moredecades until I attain the new professorial retirement age of

70 years is now much brighter.


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Figure 7: Diode laser equipment at UITH, Ilorin, Nigeria.

The last of our laser studies centred on the satisfactorystructural outcome achieved with laser treatment in thetreatment of the first published case of coat disease from

Nigeria in an eye of an 18 year old Nigerian36

. An eye withsuch a white pupil or cat eye reflex as shown in aphotograph of our patient (Figure 8) is always a sign ofserious eye disease which among infants and toddlers couldeven indicate a cancer (retinoblastoma). So, any child oradult with such sign, should be taken to be examined byophthalmologists, rather than ascribing supernatural gift ofsight to such children. We were naturally compelled to

share this unique experience with the rest of our ophthalmicsurgical colleagues in view of the fact most eye clinics inNigeria have the same diode laser that was successfullyused in our clinic and hence could expect the same goodresult if and when they have such a case.


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Figure 8: White pupil or cat eye reflex in an 18 year old Nigerian manwith Coats disease

Tertiary Prevention of Blindness and RehabilitationIt is very humbling and sad to admit that we eye care

workers sometimes fail to either prevent our patients fromgoing blind or restore sight after they might have goneblind, in spite of best efforts. The incurably or irreversiblyblind are those whose best corrected visual acuity is worsethan 3/60 and in addition their visual loss does not lenditself to improvement by standard spectacles and medical or

surgical treatment. My involvement with the issues of therehabilitation of the blind began in May 1999 when in mycapacity as the National Secretary of the nationalcommittee for Prevention of Blindness (NCPB), Icoordinated a national Braille competition for blindprimary school pupils concomitantly with a seminar on the


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prospects, problems and priorities of rehabilitation of theblind in Nigeria. Two of the main recommendations in thereport of the event37, harped on the need for NCPB to

assess the two crucial needs for the education of blindchildren in Nigeria: the material needs and secondly; andthe existing special educational facilities. The NCPBcomplied and the technical reports of these two surveyswhich are available in the NCPB secretariat are as titledbelow:

1. Educational support for the visually impaired inNigeria38.

2.

Surveys of school, manpower and resources for theeducation and welfare of the Blind in Nigeria39.

Having estimated the number of blind children ofprimary school age then (1994) to be 81,000 the NCPBreport went on to list the material needs for blind educationto include writing frames, stylus, Braille machine, watchesand thermometer, Cubarithym board and cubes; talking

calculator; abacus; adaptations of the contents of amathematical set, tape recorders, mobility canes, andordinary simple type writers. Apart from the costs of thesematerials, a blind child will also need funds for school fees,boarding materials, and transport. Our findings alsorevealed inadequacy of schools whether of the exclusiveblind type or the conventional schools integrated for blindchildren; and also blind rehabilitation centres and

workshops. The number of and distribution of qualifiedspecial teachers (sighted and/or blind) in the school thatenrolled blind students were not very impressive with thenotable exception of our very own Kwara State School forthe blind (primary), Ilorin, which then had nine suchteachers for 22 enrolled visually impaired or blind pupils.


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Later in Ilorin, our research team surveyed ourcolleague ophthalmologists in 2004 on issues relating torehabilitation, since a major barrier to accessing rehabilitation

services for the incurably blind in areas where they exist, hasbeen the lack of awareness of these services byophthalmologists and other eye care profesionals40. Amajority of the ophthalmologists indicated that they alwayscounselled their incurably blind patients, gave appropriateophthalmic care including low vision aids, and referred tosupportive and rehabilitation centres41. We concluded fromour survey that the respondents were well aware of the

optical, educational (schools, vocational, and mobilitytraining), and support services needed for the rehabilitation ofthe blind. We suggested a partnership between thegovernment, non-governmental organisations and parents tomobilise resources for the much needed improvementsrequired to bring up rehabilitation services in Nigeria toacceptable standards42. We then recommended for an updatedcompilation of available rehabilitation and existing support

facility centres and their locations within Nigeria. Thiscompilation should be circulated by the various ophthalmicprofessions (ophthalmology, optometry, and nursing) to theirmembers. Most importantly each of the rehabilitation centresand school for the blind should have a visitingophthalmologist regularly not only to provide supportiveophthalmic services but also detect some of the blind childrenin whom the cause might be curable.

Apart from formal education for blind children andvocational training for adults, functional rehabilitation shouldalso be offered through community based programmes. Theobjective in the latter is to increase the number of activitiesthat blind people can carry out in their homes and in theneighbourhoods focusing on what matters in that specificcommunity and at that stage of life 43. We noted that there is a


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need to do more than pay lip service to various internationaland national conventions and legislations which discouragediscrimination on grounds of disability in certain fields of

activity. While their blind counterparts in the developed worldhave disability living allowances and improved access tomodern technologies such as tape recorders, television andcomputer-assisted Braille devices, the blind in Nigeria do nothave such. In effect, the majority of the Nigerian blindindividuals are not formally trained as children, nor trained invocational education as adults, nor trained in mobility andother functional requirements, and consequently have their

rights to productive and dignified existence curtailed.

Appropiate TechnologyAppropriate technology is defined as local manufacture of

inexpensive but effective supplies and applications of simplepractical ideas where resources are frequently limited. It hadbeen realised that about a third of medical equipment in somemedical institutions in Nigeria were not functional because

the local culture could not sustain them44.

The standardsophisticated equipment and considerable expertise needed tocarry out computerised automated perimeter have ensured thatsuch tests are only available at tertiary health establishmentsin the cities, and not in the hinterlands where most of ourpatients reside. An inexpensive manual technology that takesadvantage of the benefits of automated perimeter andthreshold-related testing and reduces the testing time by

selecting a limited number of points in the visual field that arelikely to contain glaucoma defects was developed by Damatoand collegues45. The oculo-kinetic perimeter (OKP) chart(Figure 9) is an acceptable parametric screening test forprimary open glaucoma.


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Figure 9: The oculo-kinetic perimetric (OKP) chart


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We took up the challenge of validating the OKP chartfirstly, with a computerised KOWA automated perimeter in ourclinic and subsequently in the field on patients already diagnosed

with glaucoma46

. The OKP perimeter exhibited a sensitivity of94.7%, specifically of 98%, and an efficiency of 96.2% whencompared with the standard KOWA perimeter in diagnosedglaucoma at the rural health posts, the OKP charts gave asensitivity of 93.6%, specify of 96.8% and an efficiency of99.2%. In effect a mere cardboard chart was almost as effectiveas the electrically powered expensive computerised equipmentwith all the obvious advantages of not depending on our epilepticpublic power supply and suffering frequent technicalbreakdowns.

Our other interest in appropriate technology relates to thedesign of a suitable near-reading test chart for presbyopicilliterates who could however, somehow read in simple Arabicas a result of the residual knowledge that they gained duringtheir childhood from mandatory Quranic education for Muslimchildren. Testing for near reading is very vital to eye careworkers to enable them accurately prescribe the correct power of

reading glasses which are worn by adults from around age 40years and above. Without such reading glasses, most of us agedabove 40 years would naturally find it difficult to see clearlyprint materials and other such tiny items (our mobile phonescreens, threading of needles, etc), much more so in diminishedambient illumination. At that stage of life, we are termed aspresbyopes by eye care workers. For those who are literate, anarray of near reading test charts in Roman letters exist in Englishor vernacular languages. But for a huge majority of Muslims,they are not literate in western-style education; hence wedesigned an Arabic near-reading test chart which appropriatelytapped into the residualArabic literacy which a lot of Muslimsget exposed to while studying the Quran. A transliteration ofeach of the Arabic passages that we composed in Arabic isconcomitantly written out in Roman lettering to enable the


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attending eye care worker, irrespective of the eye care workersliteracy level in Arabic, to follow the accuracy of what his or herpatient is reading out. We successfully validated the designed

Arabic chart with the standard English one among dual-literate(Arabic and English) lecturers in Unilorin and later successfullyfield-tested it among Muslim presbyopes47. Copies of the chart(Figure 10) in form of a booklet that were printed right here inIlorin48, are currently being used in various eye clinics mostly inthe northern parts of Nigeria as aids to prescribing readingglasses.

Figure 10: Arabic near reading test chart with transliteration in Romanlettering.


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The Wu-Jones motion sensitivity screening test (MSST)is another simple practical device to detect optic nervedisease as part of community diagnoses for onchocerciasis.

We found the test to be widely accepted and easilyadministered to the rural and largely illiterate individuals inour studies

49, 50. Our results suggested that when applied in

a cross-sectional manner, the proportion of severe fielddetects in a community are more reliable predictor of theprevalence of optic nerve disease.

Manpower DevelopmentWith only about 500 ophthalmologists to render

comprehensive eye care in a country of 150 million,ophthalmologists have to delegate some of their eye careresponsibilities to other cadres of health staff (optometrists,ophthalmic nurses, community health workers, etc) for thelatter to assume some eye care functions beyond theirtraditional roles. It should be noted that this principle of

delegation had been in practice in ancient medicine whenthe Cro-Magnon man Shaman priest had a small boy whocarried his box of necessary instruments for his practice ofhealing as then conceived51. I have been privileged toparticipate in the training of basic and post basic nurses.We also prepared the module for the training of primaryeye care trainers (PECT)52 - a course which preparedexperienced ophthalmic nurses to train their colleagues and

primary health workers to basic eye care. I coordinated thefirst community eye health training (CEH) for the first setof West African Diplomate Ophthalmologists in Kaduna in1994 and also wrote two chapters in the instructional bookfor the course53,54. I was one of the key participants at theHuman Resource Development for prevention of blindness


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workshop organised by the West African PostgraduateMedical College at Ijebu Ode, Nigeria, in 199455. A ten-year action plan for the development of eye care workforce

for West Africa was drawn up at the workshop. Five yearsafterwards (1999) in a similar workshop in Accra, Ghana56,I presented the Nigeria data on Burden of Blindness andprevention of blindness activities and noted theconsiderable strides being made then in the area of sub-regional development for eye care. The various sub-regional collaborative efforts in Africa culminated in thelaunching of vision 2020 for Anglophone AfricanCountries in Pretoria, South Africa, from 17th -19th April,2000. There, I was privileged to represent Nigeria and thishappened to be my last official assignment in my capacityas the then National Coordinator for Prevention ofBlindness in Nigeria

57.

The undergraduate training of medical students, beingmy primary assignment as a medical lecturer, could be

considerably improved. In actual practice, the duration ofrotation in ophthalmology for medical students in Unilorinbarely lasts a fortnight and yet upon graduation, we expectmuch of them in eye care service. In my capacity as a long-term trainer and examiner in the final (part 2) in the WestAfrican College of Surgeons and the Nigerian NationalPostgraduate Medical College, I also have an observationon the 5-6 year-long postgraduate fellowship training. I

make bold to suggest there is an urgent need for a closeworking collaboration between our universities and thetraining colleges. The Fellowship training curriculumshould be critically appraised by the National UniversityCommission such that the academic components in thecurriculum would automatically lead to the award of either


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a combined M.Sc/PhD or a Doctor of Medicine (MD) at thecompletion of fellowship/residency training. Youngophthalmologists and other specialists interested in

academic careers would be better prepared with suchgrounding.

Health Management and Health Service ResearchThe poor health indices (inclusive of eye health), which

arise from the dysfunctional state of health care delivery inNigeria compel us all to rethink our organisationalcapabilities in health care. My approach to studying theseorganisational challenges is two-fold: firstly within thehealth care structure itself, through health service systemresearch, and secondly, through studies in generalleadership and management issues that are applicable tohealth care.

Health System Research Studies

As part of my coursework in Leadership in HealthProgrammes at the Sustainable Management TrainingCentre in Jos, Nigeria, I studied the application of TotalQuality Management (TQM) within health care setting58.By utilising the principles in studying the flow of patientswho had come for emergency eye care within thefunctional units in a tertiary eye health setting, I was able topin-point the delay with the maximal negative impact to the

stage in which the emergency eye care duty doctor (EDD)was to attend to patients. The root causes of the delay wereidentified to include:

1. Poor orientation and supervision of EDD by seniordoctors


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2. Lack of a conducive restroom for board and lodgingof EDD necessitating in his/her staying in far awayresidence

3.

Badly prepared and poorly circulated dutyschedules and rosters

4. Poor management of available support services suchas ambulance, telecommunication network andelectricity generators

Surely all these lapses were within the hospitals ambitto solve, and they were indeed immediately rectified.

Another interesting finding was the negatively-alteredhealth seeking habits of Muslim patients during the month-long annual Ramadan fast which derived from an earliercited study18.We documented that the Muslim respondentsin the study would rather not want to have any routineinteraction (clinic appointment, elective surgery) with thehealth facilities unless they had an emergency. Mundane as

this observation may sound; it has great import for healthcare delivery scheduling. The health practitioners andadministrators in areas with predominant Muslimpopulation in anticipation of the lull in activities during theRamadan month could fix routine appointments andsurgeries for Muslim patients outside this period; andschedule vacations for staff, theatre fumigations and othermaintenance works on equipment, and other such

downtime activities to the fasting period.The issue of the colossal waste of health resources byteaching hospitals having to attend to minor ailments whichour collapsed primary health care system could not attendto, was a subject of our study59. Only 191 (14.5%) of the1,321 consecutive new patients that presented at the


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ophthalmic clinic of the university of Ilorin teachinghospital between February and July 2005 actually had eyeailment that met the WHO category of the ones that needed

to have been attended to at a tertiary level of care i.e. theteaching hospitals. We recommended for a strengthenedprimary health care, a streamlining of the hazyconstitutional guidelines on the control and findings ofhealthcare and increased coordination and harmonisationsof care at the three levels of health care hierarchy.

We also studied measures that reduced costs to thepatients while still ensuring their safety and comfort. One

of these ended up reducing costs to parents and the risk ofthe complications of inhalational anaesthesia to thechildren, and also enabled our hospital to make judicioususe of her scarce anaesthesia manpower. The underlyingocular ailments which necessitated the children to besubjected to examination under anaesthesia (EUA) werefirst documented60. They included congenital glaucoma(20/33), congenital cataract (5/33) and other (8/33). SinceEUA, as routinely practised then, required inhalationanaesthetic gases and an anaesthetist, the cost was oftenprohibitive to the parents of these children. Werecommended the use of inexpensive ketamine injection toinduce the short lasting anaesthesia needed for suchprocedures in resource challenged settings. The injectioncan be administered by anaesthesia nurses who have been

well groomed in resuscitative procedures. This is a perfectwin-win situation for all the stake-holders involved whichhas been made obvious through health system research.

In our quest to further improve patient satisfaction andreduce costs, we studied how safe and effective was the useof lidocaine anaesthetic in an ointment formulation


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compared to the injectable preparation among our patientsundergoing a lancing (incision and curettage) of their eyelid internal carbuncle (chalazion)61. Apart from reduced

total pain experienced by patients, the gel preparation wasequally effective and also without the risk of the hazardsaccompanying injections.

Heeding the first part of the admonition of General SunTzu in his masterpiece: The Art of War: know thyself;know thy enemy. You will fight a thousand battles withoutdefeat; we studied the perceptions of the healthpractitioners themselves on a number of pertinent health

issues as appraised below.A persistently nagging issue in Nigeria is the role (if

any) to accord traditional eye practitioners within the eyehealth scheme of affairs. Even after about two thirds of therespondents (66%) indicated that traditional eye care wasaccepted in their community, an almost equal number(61.4%) labelled the practice as quackery62. Moreworryingly however is the finding that 56.4% of therespondents were against any form of collaborationbetween ophthalmologist and traditional practitioners. Thebarriers that the ophthalmologist identified to collaborationwith traditional practitioners included lack of scientificbasis for the healers pract ice (72.2%); secrecy on the partof healers (60.4%); non regulation of healers practice(60.4%); lack of definite format for healers practice

(53.5%); and unhealthy rivalry amongst the healers(33.6%). We recommended a form of collaboration suchthat the practice of traditional eye care could be regulated;the useful component of traditional eye care identified andencouraged (if any), the harmful aspects including, anyform of incision and couching of the lens identified and


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discouraged; and have the traditional practitioners trainedto become useful members of the health care team.

Health research in general was the subjects of our

survey among medical specialists in Nigeria 63, 64. Despitethe fact that the prototype Act of parliament that set up theteaching hospitals in Nigeria (that of UCH, Ibadan), listedthe TWO priority functions as teaching and research, withservice function only to a minimal extent needed tofacilitate teaching and research, we found out that ourcolleagues rated their research role last. The reason for thisinverse ordering of priorities may not be farfetched as we

have earlier discussed; nevertheless the development couldeven worsen the already appalling health indices in Nigeria.These stems from the fact that lack of good research hinderthe generation of new information and knowledge fordiagnosing and providing solutions; monitoring of healthsystem performance; development and production of newtechnologies and health product for tackling prioritydiseases and health conditions; and innovating ways ofaccessing and putting into effective nationwide use of theexisting cost-effective promotive, preventive, curative,rehabilitative and care preventions62. We had concludedfrom a similar survey on ophthalmic research amongNigerian ophthalmologists66,67,68 that research worksconducted by respondents were largely simple low budgetones that rarely had significant impacts and outcomes

including publications. The ophthalmologists were severelyconstrained in conducting research due to lack of access toresearch funds and finding time away from clinicalworkload. Our recommendations included retraining andemphasising on the importance of research duringundergraduate and post graduate education; and that


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adequate resources and research infrastructure should bemade available. Health facilities should also work outprotected times for ophthalmologists and other clinicians to

conduct research.

Health Management and Leadership Studies

The current dysfunctional state of healthcare inNigeria and the perpetual acrimonious workingenvironments in our tertiary health facilities both call intoquestion the management competencies of health caremanagers and leaders. As far back as 1974, Akinkugbe had

admonished that medical education in developing countriesneed to produce a physician who has been trained foruncertainties, who is resourceful and adaptable, and who isable to manage health care teams to do the best advantagewithin a limited budget; in short a health manager

69. But

almost three decades later, the findings from our survey ofWest African surgeons that the preparations that they gotfrom their formal and professional education for leadershipand management roles in health care were not optimal70.Also, most of the indices of core competencies in modernhealth leadership and management such as familiarity withsome related business and financial concepts and marketingstrategies were lacking among the respondents(surgeons)71.

We recommend for a paradigm shift from

physician land into the more business-like environmentof the emerging times, by the generality of physicians, onhealth leadership issues. Short, well focussed courses onhealth management, rather than the diffuse and amorphousMBA and MPH programmes, will greatly facilitate theattitudinal change recommended.


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Advocacy and Resource MobilisationAdvocacy for eye health essentially involves the

persuasion of those in authority or those with influence to

use their authority to promote actions that are desirable andbeneficial to eye health. Advocacy should lead to betterprovision of services and raise public awareness such thatthe public is able to put pressure on authorities orpolicymakers to allocate resources to eye health. But beforeone can advocate effectively, one must first gather highquality pieces of information on blinding eye conditions inorder to convince policy makers. Such pieces of

information in the form of executive summary of researchworks earlier carried out in Nigeria3, 5,10,21,72, have beenfound useful as advocacy tools at the various levels ofgovernance and other stake holders.

As mentioned earlier, competing priorities withinthe government budgeting allocations do not favour thehealth sector as a whole. Within the health sector itself,allocation does not favour eye health, as eye ailments donot kill, but only cause disability (blindness). Besidesbasing appeals for eye resources on the emotive intrinsicgood worth of eye health care, ophthalmologists need tocomplement this with information on the expected financialgains from eye health intervention, or to put it morebluntly, put monetary values on our much touted credo:health is wealth. Respondents in our survey on awareness

of Millennium Development Goals (MDGs) and thefeasibility of their attainability were not only aware of theMDGs but also much more importantly, adjudged thefeasibility of attaining the health related MDGs very highin Nigeria73. In another study on the interrelationshipbetween poverty and blindness, we produced hard data to


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prove that poverty is both a cause and a consequence ofblindness74. Additional backing for arguing persuasivelyfor eye health is to be found in studies which put monetary

values on the gains of making cataract eye operationsaccessible to half of the world blind. Studies have estimatedthe cost per quality adjusted life years (QALY) gained byfirst eye cataract surgery to range from $2,020 to $4,50075,76and that by the second eye surgery to be $2,72777.

All these efforts on their own hardly yield muchimpact unless they are accompanied with adequatepublicity and identification with influential patrons. All

these ingredients were in place when we organised the firstever Blindness Prevention Awareness Week and the formallaunching of an Appeal Fund for prevention of blindness inApril 1997 in Abuja, Nigeria. Having secured the officialnod of the then First Lady - Dr (Mrs) Maryam Abacha asthe chief patron, we were suffused with the attention of theprime time national electronic media and virtually all theministers of the then national government turned up andeven opened their (official) wallets. The interaction withthe members of the public live on radio went as earlierduscussed21. A live interview session at the studio of theNigerian Television Authority during the same event wasno less enriching and mutually rewarding.

The gains from the event included adequatesensitisation of the members of the public on blindness and

rehabilitation issues, advocacy of the ruling elites whograciously graced our events each day of the week - thanksto the enormous respect they had for the then powerfulFirst Lady; and the considerable resource in cash and kindthat was amassed for prevention of Blindness from asdiverse sources as the Central Bank of Nigeria, Ministries,


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international non-government organisations (INDGO); anOba from Lagos State; and the defunct Petroleum TrustFund(PTF). The Sight Savers stood out among the INDGO

as it donated vital logistics such as a Toyota Coaster bus, apower generator for each zone, office equipment andthousands of copies of health education posters. Till todaythe Sight Saver is still partnering Cross River, Kaduna,Sokoto and Kwara States in delivering much needed eyecare; and also eye research, the latest research endeavourbeing a national ocular morbidity survey with study sites inCross River, Sokoto and Kwara states with me as the

national coordinator for the study.The proceeds from the advocacy event in 1999 were

utilised by the National Committee for Prevention ofBlindness to procure diagnostic and surgical equipment foreach of the six geopolitical zones. The allocation to theNorth-Central geo-political zone was kept in the custody ofthe University of Ilorin Teaching Hospital ever since. Thevarious states within each geo-political zone were to collectthe equipment and the PTF-donated ambulance whenevereach was organising a cataract surgical eye camp from thecustodian teaching hospital. Our subsidiary plan was to alsobenefit each of the 6 custodian teaching hospitals with herfirst set of modern cataract surgical set as the ophthalmiccommunity in Nigeria then was just transiting from theobsolete form of cataract surgery (ICCE) to the new form

(ECEE).The potentials for a more dependable and steadiersource of funding health care and its eye health componentare the community national insurance scheme, the poverty-alleviated funds earmarked for health-related aspects ofMillennium Development Goal, and other sources of

f di b i id ifi d i h d Ni i H l h


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funding being identified in the proposed Nigeria HealthBill.

ConclusionsI have critically appraised my research works in the

light of how they have extended the frontiers of knowledgein the various facets of prevention of blindness activitiessuch as eye health promotion and maintenance, preventionand treatment, and rehabilitation of the blind when all elsehave failed. The recurring end point among all thesedocumented efforts is the additional gaps in our knowledge

that were further exposed and which in turn would need tobe addressed by even more research works. Though, mymentors keep assuring me that the hallmark of a goodresearch effort is the additional question it generates, Icannot help dispel my nagging feeling that it is probablythe inadequacy of the likes of myself that still leaves somuch questions to be answered.

A million Nigerians are blind and 3 out of 4 of themare avoidably blind from either preventable or curablecauses, were the appropriate eye health resources madeavailable as at when required. With people generally livinglonger these days, incidences of age-related causes ofblindness such as cataract, glaucoma and age relatedmacular diseases are on the increase. Also on the increaseis the prevalence of diabetes mellitus due to our adoption of

western-style sedentary and dietary life styles. Aversion tothe use of protective eye wears at work and leisure,inappropriate toys for our children and increasingincidences of injuries from our bad roads and inter-communal clashes are all increasing the pool of blind eyesarising from injury. Inadequate funding of the health sector

ith i li ti f th ll ti d d


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with misapplication of the meagre allocation compoundedwith discriminatory resource allocation to the eye healthsector has further ensured that a disastrous situation is

being transformed to a catastrophic one.To sum up, Mr Vice Chancellor Sir, neither are the

current efforts to prevent blindness and restore sight to thecurably blind sufficient, nor the rights of the incurablyblind to education, productive, happy and dignified lifesufficiently respected. Ophthalmologists need to knowthemselves better by leveraging strengths and minimisingweaknesses in themselves and their working environment;

and know better the enemy (blindness) through relevantresearch and mounting effective preventive measures; all ina bid to win the thousand battles within the war onblindness.

RecommendationsIt is in the light of above that I wish to make the

following specific recommendations:1.

The design of appropriate eye health messages andtheir wider dissemination in a sustained manner thatshould be facilitated by all stakeholders particularlythe federal and states ministries of health and non-governmental organisations.

2. The health facilities at the 3 levels of eye care:primary, secondary, and tertiary, should be

adequately equipped and manned to renderappropriate eye care to individuals.3. Cataract, which constitutes half of the causes of

blindness and the most cost-effective healthintervention, should be specially targeted for controlthrough a coordinated nation-wide mobile cataract

surgery programme Ophthalmologists who largely


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surgery programme. Ophthalmologists who largelyreside in cities would periodically go to the districtlevel hospitals with adequate surgical instruments,

mobility and other logistics; to operate on cataract-blind patients that would have been pooled bysuitably trained primary health workers. Funding forthis laudable venture should be sought fromcommunity insurance schemes and MillenniumDevelopment Goals (MDG) poverty alleviationfunds.

4. The training recommended at the different levels of

care include: at primary health care level,community volunteers already involved with otherdisease control efforts should be appropriatelytrained as cataract case detectors and other primarycare treatment; ophthalmic nurses at our districthospitals should be trained as refractionists in orderto provide simple presbyopic and uncomplicateddistant corrections (glasses) for refractive errors;residency training should be integrated withuniversity postgraduate programmes e.g. combinedMSc/PhD or Doctor of Medicine (MD), such that atthe completion of their training, the research andacademic potentials of the interested youngophthalmologists and other specialists, could bemaximally harnessed.

5.

Research and health management potentials ofophthalmologists and other specialists should beenhanced by giving them protected research timefrom their clinical workload and exposure to short,highly focused and relevant health managementtraining preferably at the beginning of their career.

Researchers should accord high priority to


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Researchers should accord high priority tocommunity relevant studies such as health systemresearch which in turn will lead to ways of

maximising gains from the utilisation of our meagrehealth resources.

6. Eye care workers should be more involved withhealth education and advocacy issues for the obviousbenefits of making their patients and other membersof the general public more aware of eye diseases andthe needed resources to tackle them; and moreimportantly to mobilise adequate resources from the

governments, international organisations, individualcommunities, and individual benefactors. None ofthe lofty plans to combat blindness will be realisablewithout adequate resources.

AcknowledgementsFirst and foremost, I am grateful to Allah for the

innumerable blessings that He has showered and continue

to shower on me. The latest in His infinite mercy is myappointment as the first ever Professor of Ophthalmology atthe University of Ilorin, for which I shall forever begrateful to Him. I also seek His blessings for the underlisted individuals whom the Almighty has used to nurturemy career till date.

Alhaji Alao Mahmoud, my late father, who was a

man of great intellect, humility and piety. These attributes,no doubt, informed the then Ilorin Emirate Council toappoint him as an Alikali with the absolute judicial powersassociated in those yesteryears. At his death on 26thOctober 1999, the Chief Imam of the Ilorin Emirate

divulged the poorly kept secret that Alikali Mahmoud was


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divulged the poorly kept secret that Alikali Mahmoud wasindeed a Waliyi.

Alhaja Sara Mahmoud, my mother, who always

surrendered her thrift-society savings to me to purchasemedical books, whenever I needed such, during myundergraduate school years. She had to withstand theindignity of not going on holy pilgrimage to Mecca ontime, until after my graduation - a no mean feat for anIlorin lady of her class and time.

Justice Saidu Kawu CON, JSA (RTD) assisted inkick-starting my ophthalmic career by facilitating my

appointment as an ophthalmic resident doctor in 1986. Hecontinued to take active interest in my career developmentafterwards, including physically checking on my progressduring my training in England in 1993. When recently, Itold him of my readiness to apply for a full professorship,he characteristically first made sure that I met all therequirements before giving me his blessings and more to goahead. May the Almighty Allah reward him abundantly.

Professor Shuaib Oba Abdulraheem, a formerUnilorin Vice Chancellor, is a great man of many parts tome: my secondary school teacher, my brother, my mentor,and my idol. The near uniform excellent turn out of thelecturers that were employed during his tenure at Unilorin -irrespective of their ethnic and religious background -proved his conviction right: that ability to excel has noprimordial biases; it is the opportunity to express this innateability that are not often evenly distributed.

Professor Is-haq Olanrewaju Oloyede, the Unilorincurrent Vice Chancellor, has always inspired me with hisbroad knowledge, dogged determination and raw energy.His masterly discouragement of the antics of those who

would only see merit through jaundiced eyes heavily tinted


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would only see merit through jaundiced eyes heavily tintedwith primordial outlook would forever remain a worthylegacy in the annals of our better by far university. I hope

I am already justifying the trust reposed in merit.Dr Akef El-Maghraby, a Saudi philanthropist and

ophthalmologist, awarded me a training fellowship for mysub-specialisation in vitreo-retinal surgery that wasundertaken at his palatial ultra-modern eye hospital inJeddah, Saudi Arabia in 1995 to1996.

My teachers, mentors, and senior colleagues such asProf Y. Fakunle, Deputy Vice Chancellor, Research

Training and Innovation, Unilorin (representative in Ilorinof all my undergraduate teachers); Dr J. Adido(representative in Ilorin of all my postgraduate/residencytrainers); and Professor L. Edungbola (representative inIlorin of all my mentors).

My better half, Hajia Fatima Mahmoud, andchildren: Barrister Rilwan, Nurat, Farida and Mahmoud. Icannot thank you all enough for bearing with my prolonged

absences, even on the occasions that I was around at home,since even then I would be locked up upstairs in the library.

The Emir of Ilorin Alhaji (Dr) Ibrahim SuluGambari, CFR and other members of the Ilorin EmirateTraditional Council as represented here today are gratefullyacknowledged. The Emir told me recently that he wasparticularly filled with pride with this ultimate crowningof an Emirate academic and prays for more of suchintellectual attainments by other sons and daughters of theEmirate.

My blood relatives ably led by our current familyhead and elder brother, Alhaji Oba Mahmoud, who is aretired Director in the Kwara State Judiciary. My extended

relatives who largely reside in our glorious Baboko ward


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g y gincluding our big brother Alhaji Abubakar Kawu Baraje have always been there for me as strong pillars of support.

My friends and colleagues are just too numerous tolist here.

I thank the distinguished members of the audiencefor giving me a patient hearing.

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Ilorin, Nigeria: implications for designing preventive

health education messages. The Tropical Journal of

Health Science2006; 13(2): 35-37

15. Omolase CO, Mahmoud AO, Fadamiro CO, Ayanniyi

AA, Omolade EO, Omolade BO. Eye safety

practices in rural Nigerian population in viewing solar

eclipses. Nigerian journal of Surgical Sciences2008

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16. Omolase CO, Afolabi AO, Mahmoud AO, Omolase

BO. Ocular self medication in Owo Nigeria.Nigerian

Journal Postgraduate Medical Journal2008; 1(1): 8-

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17. Omolase CO, Mahmoud AO. The welders protective

goggles: an elevation of its appreciation. Nigerian

Journal of Surgical Science2007, 17(1): 54-58

18. Mahmoud AO, Ayanniyi AA, Akanbi BT, Mosudi

KF, Balarabe HF, Ribadu DY, et al. Modifications in

ophthalmological care desired by fasting Nigerian

Muslim patients during the annual month long

Ramadan fast. Sahel Medical Journal 2007, 10(4):

123-126

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Islamic view of certain contemporary medical issues.

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non-compliance with spectacle wear in an adult

Nigerian population. African Journal of Biomedical

Research2009; 12: 43-46

21. Mahmoud AO, Perspectives of Nigerians on

prevention of blindness: implications for designing

effective eye health education messages. Centre Point

(science edition) 2005; 13(1):71-77

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Mahmoud AO, Okezue JN, Zubair SL, Akabe EA,Majekodunmi MA, Abiose A. NPPB Plan for a

nationwide cataract outreach scheme in Nigeria.

National Committee for Prevention of Blindness

Secretariat, Kaduna, Nigeria. 1999

23. Kolawole OU, Ashaye AO, Adeoti CO, Mahmoud

AO. Survey of blindness and low vision in Egbedore,

South Western Nigeria. WAJM2010; 29(5): 327-331

24. Ayanniyi AA, Mahmoud AO, Olatunji FO. Causes

and prevalence of ocular morbidity among primary

school children in Ilorin, Nigeria. Nig J Clin Pract

2010; 13(3): 248-243.

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Ayanniyi AA, Olatunji FO, Mahmoud AO, AyanniyiRO, Clinical findings among Nigerian paediatric

glaucoma suspects during a school eye health survey.

The Open Access Ophthalmology Journal 2008;

2:137-140.

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RO P f l i h l


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RO, Pattern of ocular trauma among primary school

pupils in Ilorin Nigeria.Afr Journal of Med med Sci

2009; 38: 193-196.

27. Azonobi IR, Olatunji FO, Mahmoud AO, Adido J,

Ayo-Bello A. Risk factors of manifest strabismus in

Ilorin, Nigeria.Afr J Med med Sci2009; 38: 255-260

28. Mahmoud AO, Buhari M, Adekoya BJ. Pattern of

orbito-ocular growths in Ilorin, Nigeria. TropicalJournal of Health Sciences2007; 14(1): 23-27

29. Mahmoud AO. A rare presentation of malignant

fibrous histiocytoma in the orbit of a three year old

Nigerian child. Tropical Journal of Health Sciences

2008; 15(1): 10-12

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Ayanniyi AA, Jamda AM, Badmos KB, Adelaiye RS,Mahmoud AO, Kyari F, Nwana ED. Awareness and

knowledge of ocular cancers in a resource limited

economy. North American Journal of Medical

Sciences2010; 2(11): 524-529

31. Abiose A. Jones BR, Cousens SN, Murdoch I,

Cassels-Brown A, Babalola OE, Alexander NDE,Nuhu I, Evans J, Ibrahim UF, Mahmoud AO.

Reduction in incidence of optic nerve disease with

annual ivermectin to control onchocerciasis. The

Lancet1993; 341: 130-134.

32. Umeh RE, Mahmoud AO, Hagan M, Wilson M,

Ok OI A U ET AL P l d


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Okoye OI, Asana U, ET AL. Prevalence and

distribution of ocular onchocerciasis in three

ecological zones in Nigeria.Afr J Med med Sci2010;39: 267-275

33. Mahmoud A.O. Failure of pan-retinal laser

photocoagulation to regress neovascularisation in

proliferative diabetic retinopathy.Nigerian Journal of

Ophthalmology.2005; 13(2): 54-56

34. Mahmoud AO, Kyari F, Ologunsua Y. Initial

Experience with the utility of

the sights and rights of the blind

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